Jack’s JaundiceGlands of the GI Tract1.Name the glands12.What is the differencebetween merocrine,apocrine, holocrine?23.Name the 3 salivaryglands34. What is the difference between serous (dark staining) and pale staining glands?45. What can you tell about an acinar gland that has a serous demilune?56. What is the mucuous/serous makeup of the 3 salivary glands?67. What is a myoepithelial cell?78. What are the 3 ducts in acinar glands?89. What are striated ducts?910.Which antibody is particularly present in saliva?101 Left to right: simple tubular, simple acinar, simple branched acinar2 Merocrine = exocytosis, Apocrine = membrane bound vesicles released, Holocrine = where whole cells arereleased, sebaceous glands3 Parotid, sublingual and submandibular glands4 Serous = thin watery secretion, Pale staining (Mucous) = thick mucosal secretion5 It contains both serous and mucous secreting cells6 Parotid = serous, sublingual = mucous, submandibular = mixed cells7 Found in acinar glands, secretions exit ﬁrstly into intercalated duct, then into striated duct (which decreasestonicity, like sweat glands)8 Secretions ﬁrstly into intercalated duct, then striated duct (reabsorbtion), then into excretory duct (large)9 The site of Na+ pumps which reabsorb Na+ and Cl- and replace them with K+ and HCO3- so the salivabecomes hypotonic10 IgA, secreted by plasma cells in supporting connective tissue
11.Which part of the pancreas is endocrine?1112.Other than insulin and glucagon, what other hormones are produced by Islets1213.Approximately how many lobules are there in the adult liver?1314.What is the histological structure of a hepatic lobule/portal triad?1415.What is a sinusoid?1516.What are Kupffer cells?1617.What is the function of bile salts?1718.What are bile pigments?1819.Describe the oxygenation of the blood closest the triad vs the central vein?1920.How much paracetomol relative to the recommended dose is toxic and why?2021.How much bile can the gallbladder store?2122.What type of pumps are active in the gallbladder?2223.What does cholecystokinin do?11 The Islets of Langerhans, which secrete insulin and glucagon12 Pancretic polypeptide, somatostatin13 1 million14 Each are connected to a central vein in the middle of the aciuns, surrounded by ʻtriadsʼ of bile duct, portalvein, hepatic artery15 A space where blood drains past a row of hepatocytes16 Specialised phagocytic cells only present in the liver17 Synthesised from cholesterol - function to emulsify fats in the duodenum18 Biliruben and biliverdin, breakdown products of haemoglobin19 Blood most oxygenated and nutrient rich nearest the triad, most depleted of oxygen and nutrients nearestthe central vein20 4x recommended dose, normally metabolised by P450s which can become depleted if overused. Ifdepleted, quinone binds covalently to cell proteins and kills cells. Induction of liver enzymes and alcoholpotentiates toxicity. Death slowly occurs 5 days from liver failure.21 50ml22 Na+, K+ ATPase which act to absorb water from the bile the same way as in the kidney
Epidemiology of Viral Hepatitis1. What is the difference between a virion and a nucleocapsid?232. IgG and IgA antibodies are indicative of what stages of immunity?243. What is the main pathology caused by viral hepatitis?254. What is the virus that causes hepatitis?265. What are the routes of transmission of hepatitis A and B?276. Which types of hepatitis do not cause chronic infection?287. What are the symptoms of viral hepatitis?298. What is the incubation period for hepatitis A?309. How do you diagnose Hep A?3110.What is an enteric virus?3211.What are the structural components of a hepatitis B virus?3312.What are the modes of transmission for Hep B, given that it is parenteral?3423 Virion = complete particle, Nucleocapsid = protein coat and nucleic acid24 IgM is a sign of acute or recent infection. IgG is a sign of past infection, immunisation or presence ofpassively acquired antibody.25 Inﬂammation of the liver26 Adenovirus hepatitis27 A = faecal-oral, B = parenteral (other than mouth, e.g. IV)28 A and E. Whilst B, C, and D do cause chronic infection.29 Malaise, fever, headache, jaundice, dark urine and clay coloured faeces, anorexia, vomiting.30 3-5 weeks31 Detection of Hep A virus IgM in blood samples. IgG shows past exposure and antibody.32 One which inhabits the intestinal tract33 Inner protein core around DNA and DNA polymerase, outer lipid envelope containing surface antigens34 Sexual intercourse, blood and blood products, injecting drugs, tattoos and piercings, accupuncture
13.What is the incubation period for Hep B?3514.What are icteric and anicteric?3615.What is immune dependent cytotoxicity?3716.What is the difference between active and passive immunisation?3817.How can Hep B be prevented, treated and controlled?3918.Name two antivirals used to treat Hep B4019.What percentage of Hep C carriers will experience chronic liver damage?41Bile and the Biliary System1. What stimulates bile production by the liver?422. What is cholecystokinin?433. What series of events causes the release of bile from the gallbladder?444. What is the relationship between liver blood ﬂow and bile ﬂow?4535 6 weeks to 6 months (mean 2.5 months)36 Icteric is where the infection is resolved without causing symptoms, anicteric is the carrier state 6 weeks to6 months which results in cirrhosis of the liver and carcinoma ultimately. It is possible to be an asymptomaticcarrier and this is more likely the younger you are (80% infected before 1yrs become carrier rather thanresolve infection).37 Where an effector cell of the immune system lyses a target cell whose membrane surface antigens havebeen bound by speciﬁc antibodies38 Active immunity is development of immunity following exposure to the pathogen, passive immunity isinherited antibodies. Vaccination is active immunity because you have been exposed to the pathogen anddeveloped your own antibodies to it (albeit it a non-harmful strain of the pathogen).39 Passive and active immunization, antiviral therapy, immunomodulators40 Lamivudine and Adefovir41 40-50%42 Parasympathetic impulses across the vagus nerve stimulates production in the liver43 A hormone secreted by the small intestine which signals for the release of bile from the gallbladder44 Acidic chyme entering the duodenum stimulates secretion of secretin into blood which causes ﬂow of bilefrom liver to gallbladder. Fatty acids stimulate release of CCK which causes contraction of gallbladder45 Bile ﬂow tends to increase with greater blood ﬂow to liver but is not a consequence of greater blood ﬂow
5. What are the sphincter of Oddi and ampulla ofVater?466. What co-transporters are used in the gallbladder to concentrate bile?477. What are the key differences between hepatic bile and gallbladder bile?488. What is the major component of bile and where does it come from?499. What is the relationship between bile and cholesterol?5010.Under what circumstances might you develop ‘painless jaundice’?5111.Describe the process of fatty acid absorbtion by the lumenal cells of theintestine5212.Where doVLDLS, Chylomicrons, LDLs and HDLs carry fats from and to?5313.Explain the passage of bilirubin from the blood to conjugated bilirubin in the bilecanaliculus54Alcohol - Ethanol Content of Drinks, Metabolism and Acute Effectson the Liver and CNS, and Teratogenic Effects on the DevelopingFetus46 Ampulla of Vater = where the bile duct enters the duodenum, Sphincter of Oddi = the sphincter thatcontrols this47 Na+/Cl- co-transporters are used to draw ﬂuid and salts out of the bile and concentrate it48 hepatic bile = less acidic, lower concentration of sodium, potassium, chloride, calcium, bilirubin,phospholipids, cholesterol,49 bilirubin, 85% from breakdown of red blood cells50 Bile allows cholesterol to become soluble in water51 May occur in the case of malignant obstruction of the bile duct. May be associated with anorexia, weightloss or loose stools because bile not reaching intestine. Instead it is being forced back into blood andcausing yellow tinge. However non-biliary causes should be considered, such as increased bilirubin prod.52 Micelle formed by bile salts and glycerides, long chain fatty acids taken up into cell, converted back intotriglycerides etc. in the SER, fat droplets then formed, packaged into apoproteins in the Golgi, chylomicronsand VLDLs bud off and exit the cell as vesicles via exocytosis from the basal membrane, passing into thecapillaries.53 VLDLs = from liver to adopicytes and muscle, Chylomicrons = gut to liver, LDLs = tissues to liver, HDLs =from tissues to liver to be broken down/excreted54 Bilirubin bound to albumin in the blood, separates off and enters the hepatocyte where it is reacted withUDP glucuronic acid (product of UTP and glucose) in the presence of glucronyl transferase into conjugatedbilirubin
1. How much alcohol is there in 1 unit in ml?552. How many units in a pint of beer?563. and cider...?574. How many units in a (i) small 175ml and (ii) large 250ml glass of wine?585. How many units in a single measure of spirits (40% alcohol) or a WKD bottle?596. What is the recommended daily allowance for men and women in units?607. Describe the chemical stages of metabolizing ethanol into carbon dioxide andwater618. What is the rate in units/hour that alcohol is eliminated by the body?629. What is the Km range in mM for the variants of class 1 alcohol dehydrogenasefound in the liver?6310.What types of alcohol dehydrogenase vary between ethnicities?6411.What does having a low Km for something mean in terms of afﬁnity?6512.What is associated with increased risk of colon cancer in heavy drinkers ofJapanese ethnic origin?6655 10ml of pure alcohol (which equates to 8g)56 2-3 units (2 units if weak e.g. 3%, 3 if stronger e.g. 5%)57 Roughly the same, 2-3 units/pint depending on strength58 Wine is around 15% alcohol, 2.5 units or 3.5 units in these volumes repectively59 1-1.5 units60 Men should not regularly exceed 3-4 units and women 2-361 Ethanol broken down into acetaldehyde by Cytochrome P450 (CYP2E1), alcohol dehydrogenase andcatalase; this is converted into acetate by acetaldehyde dehydrogenase. Acetate is ﬁnally broken down intoCO2 and H2062 1 unit per hour63 0.05-34mM64 ADH2 and 365 Low Km = high afﬁnity, high Km = low afﬁnity66 ALDH2 polymorphism which occurs in 40% of people with east Asian ethnicity allows acetaldehyde toreach high concentrations in blood, this is associated with increased rates of colon cancer.
13.Which drug has been given to alcoholics to deliberately cause a negative reactionif they drink excessively whilst taking it and what is its mechanism?6714.What is the mechanism of methanol poisoning?6815.Why can you get methanol poisoning in the case of alcohol consumption ifalcohol doesn’t contain methanol?6916.What would you use to treat this?7017.Describe the mechanism by which ethanol metabolism disturbs liver function7118.What are the toxic effects of acetaldehyde (enzyme used in ethanol metabolism)?7219.What is the legal blood alcohol concentration limit for driving in the UK?7320.What what blood alcohol concentration does the consumer experience grossmotor impairment and lack of physical control?7421.At what blood alcohol concentration is the gag reﬂex impaired making it possibleto choke on your own vomit?7522.What BAC is associated with the onset of coma, and possible death due torespiratory arrest?7623.Which four neuronal channels does ethanol have an intoxicating effect?7767 Antabuse (“anti-abuse”) aka disulﬁram, Inhibits aldehyde dehydrogenase so alcohol metabolised slower68 causes CNS toxicity due to formation of formic acid which disturbs neuronal mitochondrial function andcauses acidosis69 Ethanol extends the half life of methanol from 3 hours to 52 hours so it builds up in the system70 Fomepizole - a potent-long acting inhibitor of ADH71 metabolism of ethanol increases NADH/NAD+ ratio so less Acetyl CoA can enter citric acid cycle, fattyacids cannot be oxidised and accumulate, so they are be converted into triglycerides72 Interferes with proteins to produce a neoantigen (antigen within tumor cells) which leads to inﬂux ofinﬂammatory cells.73 0.08 BAC = 80mg/100ml74 0.13-0.1575 0.20 BAC76 0.40 BAC77 speciﬁc GABa channels, glutamate NMDA receptor channels, enhancement of slo-1 large conductance BKpotassium channels, thalamic T-type calcium channels
24.What is gamma-aminobutyric acid?7825.What are the most common mechanisms for alcohol dependence?7926.What are the signs of foetal alcohol syndrome?80The Liver and Protein Synthesis1. Name the two most clinically important liver synthesised proteins?812. What is ascites?823. What are the three main pathologies caused by liver disease (cirrhosis) and liverfailure?834. What is the half-life of albumin?845. What is the main cause of portal hypertension?856. Why does ﬂuid speciﬁcally accumulate in the peritoneal space in ascites?867. What are porto systemic shunts?878. What is the most common pharmacological treatment for ascites?8878 a.k.a. GABA - the chief inhibitory neurotransmitter. Inhibited by ethanol.79 Adaptation to one of the four channel effects. Enhanced dopamine (nucleus accumbens), like in otheraddictive behaviours.80 One or more dysmorphic facial features, growth deﬁciency and CNS impairment which affects learningand behaviour, reduction in size of corpus callosum, reduction in brain size in pre-frontal and parietal cortex81 Prothrombin (precursor of thrombin, which catalyses the production of soluble ﬁbrin blood clots) andalbumin (the main blood protein, contributing to the 22mmHg plasma colloid oncotic pressure)82 Accumulation of ﬂuid in the peritoneal cavity causing bloated abdominal region and often ʻmedusaʼs headʼ83 Jaundice, Ascites (ﬂuid accumulation), Encephalopathy (brain damage)84 14 days85 Reduced blood ﬂow through the liver because of liver ﬁbrosis86 Because the liver is ﬁbrosed - portal hypertension causes a backlog of ﬂuid in the abdomen whichpreferentially diffuses out into the tissues.87 New channels developed from portal circulation to systemic circulation in the presence of portalhypertension.88 Spironolactone - aldosterone antagonist
9. What is INR and why is it an indicator of acute liver failure?8910.How is aldosterone affected by failure of detoxiﬁcation/breakdown?9011.What is the cause of gynecomastia in liver damage?9112.What is the main cause of hepatic encephalopathy?9213.Why is hypoglycaemia a symptom of liver damage?9314.What are the reasons liver damage can result in malnutrition?9415.What is the consequence of the loss of Kupffer cell function?9516.What is the normal range for total bilirubin?9617.What is the median length of survival time from onset of ascites?97Oral Administration and Absorbtion of Drugs1. What is the difference between ‘pharmacokinetics’ and ‘pharmacodynamics’?982. What is bioavailablilty?9989 International Normalised Ratio - measure of blood coagulability and indicative of liver failure because ifliver stops producing prothrombin, INR changes rapidly (prothrombin half life is only 6 hours)90 A number of hormones including aldosterone buildup because they cannot be cleared by the failing liver, inthis case leads to salt and water retention contributing to ascites.91 inability to breakdown oestrogen92 Accumulation of ammonia and nitrogenous compounds resulting from inability to synthesise urea.93 Again - it is hormone dependent, because insulin cannot be broken down by liver.94 Glucose intolerance, alterations in amino acid metabolism, reduced bile acid synthesis so cannot absorbfats, ascites causes decreased appetite, hypermetabolism occurs from hormone imbalance, increasedresting energy expenditure, presence of pro-inﬂammatory cytokines,95 Bacterial challenge from the gut, frequent gram-negative infections with gut related organisms.96 3-17umol/l97 2 years98 PK = drug movement, absorbtion, distribution and metabolism, PD = site and mechanism of action99 The proportion of drug absorbed which reaches the systemic circulation. Bioavailability for an oral drug isthe ʻarea under the curveʼ as a % of what it would be compared with IV administration.
3. How might drugs cross physiological barriers in the body?1004. Why do drug plasma concentrations decline after reaching the systemiccirculation?1015. What chemical property prevents drugs from being immediately metabolised?1026. What characteristic of chemicals in portal blood makes them diffuse from bloodinto hepatocytes?1037. Which stage of drug metabolism are P450 enzymes involved in?1048. What is meant by ‘conjugation’ in relation to drug metabolism?1059. Describe the two pathways used for paracetomol metabolism under normalconditions?10610.What changes occur in paracetomol overdose and what would you give to treatan overdose? 107100 Lipid soluble or water soluble (via transporters), small molecules between cells ʻtightʼ epithelia, largermolecules ʻleakyʼ epithelia.101 Distribution - into ﬂuid compartments and tissues in relation to its physiolochemical properties andexistence of specialised tissue barriers and transporters. Clearance - metabolism and excretion by the liverand kidneys.102 Lipid solubility, metabolism aims to make drugs water soluble so they can be excreted.103 If they are lipophilic, otherwise they require the involvement of transporter proteins in the hepatocytemembrane.104 P450 enzymes are involved in the ﬁrst stage (oxidation) which takes place on the SER of hepatocytes,where the drug encounters many lipophilic surfaces105 Coupling of the drug to a substrate via an enzyme reaction (such as glucuronate, acetate or sulphate)106 1/ Conjugation with glucuronide sulphate into non-toxic metabolites (over 90%, but can becomesaturated), 2/ Metabolism by CYP450 isoforms to N-acetyl-p benzuquinone-imine (NABQI) which is toxic inlarge doses, under normal conjugation is detoxiﬁed with gluthathione.107 Glucuronide pathway becomes saturated and glutathione levels depleted so NABQI pathway becomesdepleted. So N-acetyl cysteine can be given to detoxify NABQI.